Eggsurance? A randomized controlled trial of a decision aid for elective egg freezing.

STUDY QUESTION: Does a purpose-designed Decision Aid for women considering elective egg freezing (EEF) impact decisional conflict and other decision-related outcomes? SUMMARY ANSWER: The Decision Aid reduces decisional conflict, prepares women for decision-making, and does not cause distress. WHAT IS ALREADY KNOWN: Elective egg-freezing decisions are complex, with 78% of women reporting high decisional conflict. Decision Aids are used to support complex health decisions. We developed an online Decision Aid for women considering EEF and demonstrated that it was acceptable and useful in Phase 1 testing. STUDY DESIGN, SIZE, DURATION: A single-blind, two-arm parallel group randomized controlled trial was carried out. Target sample size was 286 participants. Randomization was 1:1 to the control (existing website information) or intervention (Decision Aid plus existing website information) group and stratified by Australian state/territory and prior IVF specialist consultation. Participants were recruited between September 2020 and March 2021 with outcomes recorded over 12 months. Data were collected using online surveys and data collection was completed in March 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS: Females aged ≥18 years, living in Australia, considering EEF, proficient in English, and with internet access were recruited using multiple methods including social media posts, Google advertising, newsletter/noticeboard posts, and fertility clinic promotion. After completing the baseline survey, participants were emailed their allocated website link(s). Follow-up surveys were sent at 6 and 12 months. Primary outcome was decisional conflict (Decisional Conflict Scale). Other outcomes included distress (Depression Anxiety and Stress Scale), knowledge about egg freezing and female age-related infertility (study-specific measure), whether a decision was made, preparedness to decide about egg freezing (Preparation for Decision-Making Scale), informed choice (Multi-Dimensional Measure of Informed Choice), and decision regret (Decision Regret Scale). MAIN RESULTS AND THE ROLE OF CHANCE: Overall, 306 participants (mean age 30 years; SD: 5.2) were randomized (intervention n = 150, control n = 156). Decisional Conflict Scale scores were significantly lower at 12 months (mean score difference: -6.99 [95% CI: -12.96, -1.02], P = 0.022) for the intervention versus control group after adjusting for baseline decisional conflict. At 6 months, the intervention group felt significantly more prepared to decide about EEF than the control (mean score difference: 9.22 [95% CI: 2.35, 16.08], P = 0.009). At 12 months, no group differences were observed in distress (mean score difference: 0.61 [95% CI: -3.72, 4.93], P = 0.783), knowledge (mean score difference: 0.23 [95% CI: -0.21, 0.66], P = 0.309), or whether a decision was made (relative risk: 1.21 [95% CI: 0.90, 1.64], P = 0.212). No group differences were found in informed choice (relative risk: 1.00 [95% CI: 0.81, 1.25], P = 0.983) or decision regret (median score difference: -5.00 [95% CI: -15.30, 5.30], P = 0.337) amongst participants who had decided about EEF by 12 months (intervention n = 48, control n = 45). LIMITATIONS, REASONS FOR CAUTION: Unknown participant uptake and potential sampling bias due to the recruitment methods used and restrictions caused by the coronavirus disease 2019 pandemic. Some outcomes had small sample sizes limiting the inferences made. The use of study-specific or adapted validated measures may impact the reliability of some results. WIDER IMPLICATIONS OF THE FINDINGS: This is the first randomized controlled trial to evaluate a Decision Aid for EEF. The Decision Aid reduced decisional conflict and improved women's preparation for decision making. The tool will be made publicly available and can be tailored for international use. STUDY FUNDING/COMPETING INTEREST(S): The Decision Aid was developed with funding from the Royal Women's Hospital Foundation and McBain Family Trust. The study was funded by a National Health and Medical Research Council (NHMRC) Project Grant APP1163202, awarded to M. Hickey, M. Peate, R.J. Norman, and R. Hart (2019-2021). S.S., M.P., D.K., and S.B. were supported by the NHMRC Project Grant APP1163202 to perform this work. R.H. is Medical Director of Fertility Specialists of Western Australia and National Medical Director of City Fertility. He has received grants from MSD, Merck-Serono, and Ferring Pharmaceuticals unrelated to this study and is a shareholder of CHA-SMG. R.L. is Director of Women's Health Melbourne (Medical Practice), ANZSREI Executive Secretary (Honorary), RANZCOG CREI Subspecialty Committee Member (Honorary), and a Fertility Specialist at Life Fertility Clinic Melbourne and Royal Women's Hospital Public Fertility Service. R.A.A. has received grants from Ferring Pharmaceuticals unrelated to this study. M.H., K.H., and R.J.N. have no conflicts to declare. TRIAL REGISTRATION NUMBER: ACTRN12620001032943. TRIAL REGISTRATION DATE: 11 August 2020. DATE OF FIRST PATIENT'S ENROLMENT: 29 September 2020.

Socio-demographic correlates of unhealthy lifestyle in Ethiopia: a secondary analysis of a national survey.

BACKGROUND: Multiple lifestyle risk factors exhibit a stronger association with non-communicable diseases (NCDs) compared to a single factor, emphasizing the necessity of considering them collectively. By integrating these major lifestyle risk factors, we can identify individuals with an overall unhealthy lifestyle, which facilitates the provision of targeted interventions for those at significant risk of NCDs. The aim of this study was to evaluate the socio-demographic correlates of unhealthy lifestyles among adolescents and adults in Ethiopia. METHODS: A national cross-sectional survey, based on the World Health Organization's NCD STEPS instruments, was conducted in Ethiopia. The survey, carried out in 2015, involved a total of 9,800 participants aged between 15 and 69 years. Lifestyle health scores, ranging from 0 (most healthy) to 5 (most unhealthy), were derived considering factors such as daily fruit and vegetable consumption, smoking status, prevalence of overweight/obesity, alcohol intake, and levels of physical activity. An unhealthy lifestyle was defined as the co-occurrence of three or more unhealthy behaviors. To determine the association of socio-demographic factors with unhealthy lifestyles, multivariable logistic regression models were utilized, adjusting for metabolic factors, specifically diabetes and high blood pressure. RESULTS: Approximately one in eight participants (16.7%) exhibited three or more unhealthy lifestyle behaviors, which included low fruit/vegetable consumption (98.2%), tobacco use (5.4%), excessive alcohol intake (15%), inadequate physical activity (66%), and obesity (2.3%). Factors such as male sex, urban residency, older age, being married or in a common-law relationship, and a higher income were associated with these unhealthy lifestyles. On the other hand, a higher educational status was associated with lower odds of these behaviors. CONCLUSION: In our analysis, we observed a higher prevalence of concurrent unhealthy lifestyles. Socio-demographic characteristics, such as sex, age, marital status, residence, income, and education, were found to correlate with individuals' lifestyles. Consequently, tailored interventions are imperative to mitigate the burden of unhealthy lifestyles in Ethiopia.

Is there a relationship between intensity of occupational therapy and functional outcomes in hospitalised older patients? A prospective cohort study.

INTRODUCTION: Delivering high-intensity occupational therapy can improve functional outcomes for patients and reduce length of stay. However, there is little published evidence of this in the aged rehabilitation setting. This study aims to explore the association between intensity of occupational therapy interventions and functional outcomes in geriatric rehabilitation inpatients. METHODS: A prospective cohort study was conducted with adult inpatients admitted to a geriatric rehabilitation program. The intervention was the intensity of occupational therapy measured as high (≥30 minutes per day) versus low (<30 minutes per day). The primary outcome measured was change in functional performance, defined as a minimum of half a point improvement in the Katz Index of Activities of Daily Living (ADL) and/or the Lawton and Brody Scale of Instrumental ADL (IADL) at admission to rehabilitation, discharge and 3months post-discharge. RESULTS: A total of 693 patients were included in the analysis. The mean age was 82.2 years (standard deviation [SD] = 7.9), 57% were females, and 64% had cognitive impairment. Patients (n = 210) who received greater than or equal to 30 minutes of occupational therapy daily were more likely to have clinically relevant functional improvements.; for both ADL (odds ratio [OR] = 1.87, 95% confidence interval [CI]: 1.24-2.83) and IADL (OR = 3.00, 95% CI: 1.96-4.61), after adjusting for age, sex, severity of function (ADL ≤ 2) at admission, frailty and cognitive impairment. Improvements in ADL and IADL were maintained for at least 3 months following discharge. CONCLUSION: This study found that geriatric rehabilitation inpatients who received higher intensity of occupational therapy interventions were more likely to functionally improve than those who received lower intensity. Further research is required to determine if other factors, such as therapy type, influence functional outcomes.

A systematic review of trends in all-cause mortality among people with diabetes.

AIMS/HYPOTHESIS: We examined all-cause mortality trends in people with diabetes and compared them with trends among people without diabetes. METHODS: MEDLINE, EMBASE and CINAHL databases were searched for observational studies published from 1980 to 2019 reporting all-cause mortality rates across ≥2 time periods in people with diabetes. Mortality trends were examined by ethnicity, age and sex within comparable calendar periods. RESULTS: Of 30,295 abstracts screened, 35 studies were included, providing data on 69 separate ethnic-specific or sex-specific populations with diabetes since 1970. Overall, 43% (3/7), 53% (10/19) and 74% (32/43) of the populations studied had decreasing trends in all-cause mortality rates in people with diabetes in 1970-1989, 1990-1999 and 2000-2016, respectively. In 1990-1999 and 2000-2016, mortality rates declined in 75% (9/12) and 78% (28/36) of predominantly Europid populations, and in 14% (1/7) and 57% (4/7) of non-Europid populations, respectively. In 2000-2016, mortality rates declined in 33% (4/12), 65% (11/17), 88% (7/8) and 76% (16/21) of populations aged <40, 40-54, 55-69 and ≥70 years, respectively. Among the 33 populations with separate mortality data for those with and without diabetes, 60% (6/10) of the populations with diabetes in 1990-1999 and 58% (11/19) in 2000-2016 had an annual reduction in mortality rates that was similar to or greater than in those without diabetes. CONCLUSIONS/INTERPRETATION: All-cause mortality has declined in the majority of predominantly Europid populations with diabetes since 2000, and the magnitude of annual mortality reduction matched or exceeded that observed in people without diabetes in nearly 60% of populations. Patterns of diabetes mortality remain uncertain in younger age groups and non-Europid populations. REGISTRATION: PROSPERO registration ID CRD42019095974. Graphical abstract.

Trends in Incidence of ESKD in People With Type 1 and Type 2 Diabetes in Australia, 2002-2013.

RATIONALE & OBJECTIVE: The number of people with diabetes and end-stage kidney disease (ESKD) is increasing worldwide, but it is unknown whether this indicates an increasing risk for ESKD in people with diabetes. We examined temporal trends in the incidence of ESKD within the Australian population with diabetes from 2002 to 2013. STUDY DESIGN: Follow-up study using a national health care services registry. SETTING & PARTICIPANTS: Registrants with type 1 or type 2 diabetes in Australia's National Diabetes Services Scheme (NDSS). PREDICTORS: Age, sex, indigenous status, diabetes type, and calendar year. OUTCOME: Incidence of ESKD (dialysis or kidney transplantation) or death ascertained using the Australian and New Zealand Dialysis and Transplant Registry and the Australian national death index. ANALYTICAL APPROACH: NDSS registrants were followed up from 2002 or date of registration until onset of ESKD, death, or December 31, 2013. The incidence of ESKD in type 1 diabetes was calculated only in those younger than 55 years. RESULTS: Among 1,375,877 registrants between 2002 and 2013, a total of 9,977 experienced incident ESKD, representing an overall incidence of ESKD in people with diabetes of 10.0 (95% CI, 9.8-10.2) per 10,000 person-years. Among those with type 1 diabetes, the age-standardized annual incidence was stable during the study period. Among those with type 2 diabetes, the incidence increased in nonindigenous people (annual percentage change, 2.2%; 95% CI, 0.4%-4.1%) with the greatest increases in those younger than 50 and those older than 80 years. No significant change over time was observed in indigenous people, although the adjusted incident rate ratio for indigenous versus nonindigenous was 4.03 (95% CI, 3.68-4.41). LIMITATIONS: Lack of covariates such as comorbid conditions, medication use, measures of quality of care, and baseline kidney function. CONCLUSIONS: The age-standardized annual incidence of ESKD increased in Australia from 2002 to 2013 for nonindigenous people with type 2 diabetes but was stable for people with type 1 diabetes. Efforts to prevent the development of ESKD, especially among indigenous Australians and those with early-onset type 2 diabetes, are warranted.

Risk of Progression of Nonalbuminuric CKD to End-Stage Kidney Disease in People With Diabetes: The CRIC (Chronic Renal Insufficiency Cohort) Study.

BACKGROUND: Reduced glomerular filtration rate (GFR) in the absence of albuminuria is a common manifestation of chronic kidney disease (CKD) in diabetes. However, the frequency with which it progresses to end-stage kidney disease (ESKD) is unknown. STUDY DESIGN: Multicenter prospective cohort study. SETTING & PARTICIPANTS: We included 1,908 participants with diabetes and reduced GFR enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study in the United States. PREDICTORS: Urinary albumin and protein excretion. OUTCOMES: Incident ESKD, CKD progression (ESKD or ≥50% reduction in estimated GFR [eGFR] from baseline), and annual rate of decline in kidney function. MEASUREMENTS: ESKD was ascertained by self-report and by linkage to the US Renal Data System. We used Cox proportional hazards modeling to estimate the association of albuminuria and proteinuria with incident ESKD or CKD progression and linear mixed-effects models to assess differences in eGFR slopes among those with and without albuminuria. RESULTS: Mean eGFR at baseline was 41.2mL/min/1.73m2. Normal or mildly increased 24-hour urinary albumin excretion (<30mg/d) at baseline was present in 28% of participants, but in only 5% of those progressing to ESKD. For those with baseline normal or mildly increased albuminuria, moderately increased albuminuria (albumin excretion, 30-299mg/d), and 2 levels of severely increased albuminuria (albumin excretion, 300-999 and ≥1,000mg/d): crude rates of ESKD were 7.4, 34.8, 78.7, and 178.7 per 1,000 person-years, respectively; CKD progression rates were 17.0, 61.4, 130.5, and 295.1 per 1,000 person-years, respectively; and annual rates of eGFR decline were -0.17, -1.35, -2.74, and -4.69mL/min/1.73m2, respectively. LIMITATIONS: We were unable to compare the results with healthy controls. CONCLUSIONS: In people with diabetes with reduced eGFRs, the absence of albuminuria or proteinuria is common and carries a much lower risk for ESKD, CKD progression, or rapid decline in eGFR compared with those with albuminuria or proteinuria. The rate of eGFR decline in normoalbuminuric CKD was similar to that reported for the general diabetic population.

Health map for HealthGap: Defining a geographical catchment to examine cardiovascular risk in Victoria, Australia.

The HealthGap study aimed to understand cardiovascular risk among Indigenous Australians in Victoria using linked administrative data. A key challenge was differing spatial coverages of sources: state-level data for risk factors but cardiovascular outcomes for three hospitals. Catchments were defined based on hospital postcodes to estimate denominator populations for risk modelling: first- and second-order neighbours, and spatial distribution of outcomes ('spatial event distribution'). Catchment coverage was assessed through proportions of patients presenting to study hospitals from catchment postcodes. The spatial event distribution performed best, capturing 82% events overall (first-order:40%; second-order:64%) and 65% Indigenous (27% and 45%). No approach excluded proximal non-study hospitals. Spatial event distributions could help define denominator populations when geographic information on outcome data is available but may not avoid potential misclassification.

Can flash glucose monitoring improve glucose management for Aboriginal and Torres Strait Islander peoples with type 2 diabetes? A protocol for a randomised controlled trial.

BACKGROUND: Aboriginal and Torres Strait Islander peoples are disproportionately impacted by type 2 diabetes. Continuous glucose monitoring (CGM) technology (such as Abbott Freestyle Libre 2, previously referred to as Flash Glucose Monitoring) offers real-time glucose monitoring that is convenient and easy to use compared to self-monitoring of blood glucose (SMBG). However, this technology's use is neither widespread nor subsidised for Aboriginal and Torres Strait Islander peoples with type 2 diabetes. Building on existing collaborations with a national network of Aboriginal and Torres Strait Islander communities, this randomised controlled trial aims to assess the effect of CGM compared to SMBG on (i) haemoglobin A1c (HbA1c), (ii) achieving blood glucose targets, (iii) reducing hypoglycaemic episodes and (iv) cost-effective healthcare in an Aboriginal and Torres Strait Islander people health setting. METHODS: This is a non-masked, parallel-group, two-arm, individually randomised, controlled trial (ACTRN12621000753853). Aboriginal and Torres Strait Islander adults with type 2 diabetes on injectable therapy and HbA1c ≥ 7.5% (n = 350) will be randomised (1:1) to CGM or SMBG for 6 months. The primary outcome is change in HbA1c level from baseline to 6 months. Secondary outcomes include (i) CGM-derived metrics, (ii) frequency of hypoglycaemic episodes, (iii) health-related quality of life and (iv) incremental cost per quality-adjusted life year gained associated with the CGM compared to SMBG. Clinical trial sites include Aboriginal Community Controlled Organisations, Aboriginal Medical Services, primary care centres and tertiary hospitals across urban, rural, regional and remote Australia. DISCUSSION: The trial will assess the effect of CGM compared to SMBG on HbA1c for Aboriginal and Torres Strait Islander people with type 2 diabetes in Australia. This trial could have long-term benefits in improving diabetes management and providing evidence for funding of CGM in this population. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12621000753853. Registered on 15th June 2021.

Corrigendum to "RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned" [Eur. Urol. Open Sci. 54 (2023) 33-42].

[This corrects the article DOI: 10.1016/j.euros.2023.05.007.].

Prevalence and determinants of early antenatal care visit among pregnant women attending antenatal care in Debre Berhan Health Institutions, Central Ethiopia.

Antenatal care (ANC), which is given to pregnant women, is widely used for prevention, early diagnosis and treatment of general medical and pregnancy-related complications. This study assessed the prevalence of early ANC visit and associated factors among pregnant women attending ANC in Debre Berhan town. An institution based cross-sectional study design was used to collect data from pregnant mothers with a face to face interview technique. Bivariate and multivariate analyses were used to identify associated factors for early ANC visit. A total of 446 pregnant women were included in the study. One hundred seventeen (26.2%) pregnant mothers started their first ANC visit early. The multivariate analysis showed that mothers with no parity before (AOR = 3.65, 95% CI: 2.14, 6.24), had good knowledge on early ANC (AOR = 3.10, 95% CI: 1.80, 5.33) and planned pregnancy (AOR = 1.66, 95% CI: 1.06, 2.61) were significantly associated with early ANC visit. The prevalence of early ANC visit was low. Awareness creation on the importance of early ANC visit needs to be emphasized at the time of service provision as well as at community levels.

RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned.

Background: The surgical difficulty of partial nephrectomy (PN) varies depending on the operative approach. Existing nephrometry classifications for assessment of surgical difficulty are not specific to the robotic approach. Objective: To develop an international robotic-specific classification of renal masses for preoperative assessment of surgical difficulty of robotic PN. Design setting and participants: The RPN classification (Radius, Position of tumour, iNvasion of renal sinus) considers three parameters: tumour size, tumour position, and invasion of the renal sinus. In an international survey, 45 experienced robotic surgeons independently reviewed de-identified computed tomography images of 144 patients with renal tumours to assess surgical difficulty of robot-assisted PN using a 10-point Likert scale. A separate data set of 248 patients was used for external validation. Outcome measurements and statistical analysis: Multiple linear regression was conducted and a risk score was developed after rounding the regression coefficients. The RPN classification was correlated with the surgical difficulty score derived from the international survey. External validation was performed using a retrospective cohort of 248 patients. RPN classification was also compared with the RENAL (Radius; Exophytic/endophytic; Nearness; Anterior/posterior; Location), PADUA (Preoperative Aspects and Dimensions Used for Anatomic), and SPARE (Simplified PADUA REnal) scoring systems. Results and limitation: The median tumour size was 38 mm (interquartile range 27-49). The majority (81%) of renal tumours were peripheral, followed by hilar (12%) and central (7.6%) locations. Noninvasive and semi-invasive tumours accounted for 37% each, and 26% of the tumours were invasive. The mean surgical difficulty score was 5.2 (standard deviation 1.9). Linear regression analysis indicated that the RPN classification correlated very well with the surgical difficulty score (R2 = 0.80). The R2 values for the other scoring systems were: 0.66 for RENAL, 0.75 for PADUA, and 0.70 for SPARE. In an external validation cohort, the performance of all four classification systems in predicting perioperative outcomes was similar, with low R2 values. Conclusions: The proposed RPN classification is the first nephrometry system to assess the surgical difficulty of renal masses for which robot-assisted PN is planned, and is a useful tool to assist in surgical planning, training and data reporting. Patient summary: We describe a simple classification system to help urologists in preoperative assessment of the difficulty of robotic surgery for partial kidney removal for kidney tumours.

Efficacy of Flash Glucose Monitoring in Type 1 and Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

Objective: Flash glucose monitoring (FlashGM) is a sensor-based technology that displays glucose readings and trends to people with diabetes. In this meta-analysis, we assessed the effect of FlashGM on glycaemic outcomes including HbA1c, time in range, frequency of hypoglycaemic episodes and time in hypo/hyperglycaemia compared to self-monitoring of blood glucose, using data from randomised controlled trials. Methods: A systematic search was conducted on MEDLINE, EMBASE and CENTRAL for articles published between 2014 and 2021. We selected randomised controlled trials comparing flash glucose monitoring to self-monitoring of blood glucose that reported change in HbA1c and at least one other glycaemic outcome in adults with type 1 or type 2 diabetes. Two independent reviewers extracted data from each study using a piloted form. Meta-analyses using a random-effects model was conducted to obtain a pooled estimate of the treatment effect. Heterogeneity was assessed using forest plots and the I2 statistic. Results: We identified 5 randomised controlled trials lasting 10 - 24 weeks and involving 719 participants. Flash glucose monitoring did not lead to a significant reduction in HbA1c. However, it resulted in increased time in range (mean difference 1.16 hr, 95% CI 0.13 to 2.19, I2 = 71.7%) and decreased frequency of hypoglycaemic episodes (mean difference -0.28 episodes per 24 hours, 95% CI -0.53 to -0.04, I2 = 71.4%). Conclusions: Flash glucose monitoring did not lead to a significant reduction in HbA1c compared to self-monitoring of blood glucose, however, it improved glycaemic management through increased time in range and decreased frequency of hypoglycaemic episodes. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier PROSPERO (CRD42020165688).

Can patterns of medication use explain the increasing incidence of end stage kidney disease among people with diabetes in Australia?

AIMS: Recently, an increase in the incidence of end-stage kidney disease (ESKD) among people with type 2 diabetes (T2D) aged < 50 years and ≥ 80 years has been observed in Australia. We examined whether patterns of medication use are likely to explain these trends. METHODS: Among National Diabetes Services Scheme registrants, we determined the annual prevalence of dispensed glucose-lowering (GL), blood-pressure-lowering (BPL) and lipid-lowering (LL) agents with ≥3, ≥6 or ≥9 dispensings per year from 2003 to 2013. Relative changes in the prevalence were determined via Poisson regression. RESULTS: During 2003-2013, the percentage of people with T2D dispensed GL, BPL and LL agents with ≥3, ≥6 or ≥9 dispensings per year increased in all age-groups. From 2003 to 2013, GL, BPL and LL agents use with ≥3 dispensings per year increased by 17%, 8.2%, and 53%, respectively. The use of renin-angiotensin-aldosterone-system-blockers over time also increased but more slowly in those aged <60 years compared to those aged ≥80 years (6% vs 18%, p < 0.001). CONCLUSIONS: Changes in medication use are not likely to explain increasing incidence of ESKD in younger Australians with T2D. Studies are needed to provide insights into the major drivers of the rising incidence of ESKD in this population.

Threat of COVID-19 impacting on a quaternary healthcare service: a retrospective cohort study of administrative data.

OBJECTIVES: The threat of a pandemic, over and above the disease itself, may have significant and broad effects on a healthcare system. We aimed to describe the impact of the SARS-CoV-2 pandemic (during a relatively low transmission period) and associated societal restrictions on presentations, admissions and outpatient visits. DESIGN: We compared hospital activity in 2020 with the preceding 5 years, 2015-2019, using a retrospective cohort study design. SETTING: Quaternary hospital in Melbourne, Australia. PARTICIPANTS: Emergency department presentations, hospital admissions and outpatient visits from 1 January 2015 to 30 June 2020, n=896 934 episodes of care. INTERVENTION: In Australia, the initial peak COVID-19 phase was March-April. PRIMARY AND SECONDARY OUTCOME MEASURES: Separate linear regression models were fitted to estimate the impact of the pandemic on the number, type and severity of emergency presentations, hospital admissions and outpatient visits. RESULTS: During the peak COVID-19 phase (March and April 2020), there were marked reductions in emergency presentations (10 389 observed vs 14 678 expected; 29% reduction; p<0.05) and hospital admissions (5972 observed vs 8368 expected; 28% reduction; p<0.05). Stroke (114 observed vs 177 expected; 35% reduction; p<0.05) and trauma (1336 observed vs 1764 expected; 24% reduction; p<0.05) presentations decreased; acute myocardial infarctions were unchanged. There was an increase in the proportion of hospital admissions requiring intensive care (7.0% observed vs 6.0% expected; p<0.05) or resulting in death (2.2% observed vs 1.5% expected; p<0.05). Outpatient attendances remained similar (30 267 observed vs 31 980 expected; 5% reduction; not significant) but telephone/telehealth consultations increased from 2.5% to 45% (p<0.05) of total consultations. CONCLUSIONS: Although case numbers of COVID-19 were relatively low in Australia during the first 6 months of 2020, the impact on hospital activity was profound.

COVID-19 in Ethiopia: a geospatial analysis of vulnerability to infection, case severity and death.

BACKGROUND: COVID-19 has caused a global public health crisis affecting most countries, including Ethiopia, in various ways. This study maps the vulnerability to infection, case severity and likelihood of death from COVID-19 in Ethiopia. METHODS: Thirty-eight potential indicators of vulnerability to COVID-19 infection, case severity and likelihood of death, identified based on a literature review and the availability of nationally representative data at a low geographic scale, were assembled from multiple sources for geospatial analysis. Geospatial analysis techniques were applied to produce maps showing the vulnerability to infection, case severity and likelihood of death in Ethiopia at a spatial resolution of 1 km×1 km. RESULTS: This study showed that vulnerability to COVID-19 infection is likely to be high across most parts of Ethiopia, particularly in the Somali, Afar, Amhara, Oromia and Tigray regions. The number of severe cases of COVID-19 infection requiring hospitalisation and intensive care unit admission is likely to be high across Amhara, most parts of Oromia and some parts of the Southern Nations, Nationalities and Peoples' Region. The risk of COVID-19-related death is high in the country's border regions, where public health preparedness for responding to COVID-19 is limited. CONCLUSION: This study revealed geographical differences in vulnerability to infection, case severity and likelihood of death from COVID-19 in Ethiopia. The study offers maps that can guide the targeted interventions necessary to contain the spread of COVID-19 in Ethiopia.

Third-Line Antidiabetic Therapy Intensification Patterns and Glycaemic Control in Patients with Type 2 Diabetes in the USA: A Real-World Study.

BACKGROUND: Third-line antidiabetic drug (ADD) intensification patterns and glycemic control post intensification in type 2 diabetes mellitus (T2DM) have not been thoroughly explored in a real-world setting. OBJECTIVE: This study explored the patterns and risks of third-line ADD intensification post second-line ADDs and the probability of desirable glucose control over 12 months by third-line ADD classes at the population level. METHODS: We used the electronic medical records of 255,236 patients with T2DM in the USA initiating a second-line ADD post metformin from January 2013 to evaluate the rates and risks of third-line intensification and the probability of desirable glycemic control with different ADDs after addressing inherent heterogeneity using appropriate methodologies. RESULTS: Patients had a mean age of 60 years and glycated hemoglobin (HbA1c) of 8.5% at second-line ADD. Over 209,136 person-years (PY) of follow-up, 40% had initiated a third-line ADD at HbA1c of 8.8%. Patients receiving dipeptidyl peptidase-4 inhibitors (DPP-4i) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) as the second-line ADD had a 7% (95% hazard ratio [HR] confidence interval [CI] 1.05-1.10) and 28% (95% HR CI 1.24-1.33) higher adjusted risk of intensifying with a third-line ADD than did those receiving sulfonylureas as the second-line ADD. Those receiving sodium-glucose cotransporter-2 inhibitors (SGLT-2i) as second-line ADD had a 17% (95% HR CI 0.80-0.87) lower risk. The adjusted probability of reducing HbA1c by ≥ 1% was similar in those receiving third-line sulfonylureas, thiazolidinediones, GLP-1 RAs, SGLT-2i, and insulin (minimum, maximum 95% CI of probability 0.61, 0.68), whereas those receiving DPP-4i had a significantly lower probability (0.58; 95% CI 0.56-0.59). Similarly, the probability of reducing HbA1c < 7.5% was similar in the sulfonylurea, GLP-1 RA, and SGLT-2i groups (minimum, maximum of 95% CI of probability 0.41, 0.49), whereas those receiving DPP-4i had a significantly lower probability of achieving an HbA1c < 7.5% (0.37; 95% CI 0.36-0.38). CONCLUSION: This study, based on a large representative cohort of patients with T2DM from the USA, suggests the need for revisiting real-world practices in choosing therapeutic intensification pathways and a more proactive strategy to tackle the persistent risk factor burden in patients with T2DM.

Temporal Trend in Young-Onset Type 2 Diabetes-Macrovascular and Mortality Risk: Study of U.K. Primary Care Electronic Medical Records.

OBJECTIVE: To evaluate temporal prevalence trend, cardiometabolic risk factors, and the risk of atherosclerotic cardiovascular disease (ASCVD) and all-cause mortality (ACM) in incident young- and usual-onset type 2 diabetes. RESEARCH DESIGN AND METHODS: From the U.K. primary care database, 370,854 people with a new diagnosis of type 2 diabetes from 2000 to 2017 were identified. Analyses were conducted by age-group (18-39, 40-49, 50-59, 60-69, 70-79 years) and high-/low-risk status without history of ASCVD at diagnosis, with subjects with two or more of current smoking, high systolic blood pressure, high LDL cholesterol (LDL-C), or chronic kidney disease classified as high risk. RESULTS: The proportion of people aged <50 years at diagnosis increased during 2000-2010 and then stabilized. The incidence rates of ASCVD and ACM declined in people aged ≥50 years but did not decrease in people <50 years. Compared with people aged ≥50 years, those aged 18-39 years at diagnosis had a higher proportion of obesity (71% obese) and higher HbA1c (8.6%), and 71% had high LDL-C, while only 18% were on cardioprotective therapy. Although 2% in this age-group had ASCVD at diagnosis, 23% were identified as high risk. In the 18-39-year age-group, the adjusted average years to ASCVD/ACM in high-risk individuals (9.1 years [95% CI 8.2-10.0]/9.3 years [8.1-10.4]) were similar to the years in those with low risk (10.0 years [9.5-10.5]/10.5 years [9.7-11.2]). However, individuals aged ≥50 years with high risk were likely to experience an ASCVD event 1.5-2 years earlier and death 1.1-1.5 years earlier compared with low-risk groups (P < 0.01). CONCLUSIONS: Unlike usual-onset, young-onset type 2 diabetes has similar cardiovascular and mortality risk irrespective of cardiometabolic risk factor status at diagnosis. The guidelines on the management of young-onset type 2 diabetes for intensive risk factor management and cardioprotective therapies need to be urgently reevaluated through prospective studies.

Risk of Rapid Kidney Function Decline, All-Cause Mortality, and Major Cardiovascular Events in Nonalbuminuric Chronic Kidney Disease in Type 2 Diabetes.

OBJECTIVE: We aimed to investigate the rate of progression of nonalbuminuric chronic kidney disease (CKD) to end-stage kidney disease (ESKD) or death or major cardiovascular events (MACE) compared with albuminuric and nonalbuminuric phenotypes. RESEARCH DESIGN AND METHODS: We included 10,185 participants with type 2 diabetes enrolled in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study. Based on baseline albuminuria and estimated glomerular filtration rate (eGFR), participants were classified as having no kidney disease (no CKD), albuminuria only (albuminuric non-CKD), reduced eGFR only (nonalbuminuric CKD), or both albuminuria and reduced eGFR (albuminuric CKD). The rate of eGFR decline and hazard ratios (HRs) for ESKD or death or MACE were calculated. RESULTS: For individuals with no CKD and those with nonalbuminuric CKD, the rates of eGFR decline were -1.31 and -0.60 mL/min/year, respectively (P < 0.001). In competing-risks analysis (no CKD as the reference), HRs for ESKD indicated no increased risk for nonalbuminuric CKD (0.76 [95% CI 0.34, 1.70]) and greatest risk for albuminuric CKD (4.52 [2.91, 7.01]). In adjusted Cox models, HRs for death and MACE were highest for albumuniuric CKD (2.38 [1.92, 2.90] and 2.37 [1.89, 2.97], respectively) and were higher for albuminuric non-CKD (1.82 [1.59, 2.08] and 1.88 [1.63, 2.16], respectively) than for those with nonalbuminuric CKD (1.42 [1.14, 1.78] and 1.44 [1.13, 1.84], respectively). CONCLUSIONS: Those with nonalbuminuric CKD showed a slower rate of decline in eGFR than did any other group; however, these individuals still carry a greater risk for death and MACE than do those with no CKD.

Trends in incidence of total or type 2 diabetes: systematic review.

OBJECTIVE: To assess what proportions of studies reported increasing, stable, or declining trends in the incidence of diagnosed diabetes. DESIGN: Systematic review of studies reporting trends of diabetes incidence in adults from 1980 to 2017 according to PRISMA guidelines. DATA SOURCES: Medline, Embase, CINAHL, and reference lists of relevant publications. ELIGIBILITY CRITERIA: Studies of open population based cohorts, diabetes registries, and administrative and health insurance databases on secular trends in the incidence of total diabetes or type 2 diabetes in adults were included. Poisson regression was used to model data by age group and year. RESULTS: Among the 22 833 screened abstracts, 47 studies were included, providing data on 121 separate sex specific or ethnicity specific populations; 42 (89%) of the included studies reported on diagnosed diabetes. In 1960-89, 36% (8/22) of the populations studied had increasing trends in incidence of diabetes, 55% (12/22) had stable trends, and 9% (2/22) had decreasing trends. In 1990-2005, diabetes incidence increased in 66% (33/50) of populations, was stable in 32% (16/50), and decreased in 2% (1/50). In 2006-14, increasing trends were reported in only 33% (11/33) of populations, whereas 30% (10/33) and 36% (12/33) had stable or declining incidence, respectively. CONCLUSIONS: The incidence of clinically diagnosed diabetes has continued to rise in only a minority of populations studied since 2006, with over a third of populations having a fall in incidence in this time period. Preventive strategies could have contributed to the fall in diabetes incidence in recent years. Data are limited in low and middle income countries, where trends in diabetes incidence could be different. SYSTEMATIC REVIEW REGISTRATION: Prospero CRD42018092287.

The effect of nurse prescribers on glycaemic control in type 2 diabetes: A systematic review and meta-analysis.

BACKGROUND: The creation of advanced nursing roles in diabetes management, with specific skills such as nurse prescribing, has resulted in nurses taking on roles that have traditionally been associated with doctors. OBJECTIVES: We aimed to examine the effectiveness of nurse-led clinics, in which nurses were involved in prescribing, on haemoglobin A1c (HbA1c) among people with type 2 diabetes. METHODS: We systematically searched the literature, Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE and Allied Health Literature database guide (CINAHL) databases, to identify randomised controlled trials (RCTs) assessing the effect of nurse prescribers on HbA1c. We focused on randomised controlled trials which compared nurse prescriber interventions with usual care in adults aged 18 years or over with a diagnosis of type 2 diabetes. The main outcome measure was change in HbA1c levels. We performed a random effects model meta-analysis to assess the pooled effect size of the intervention. Studies were divided into two groups according to the role of nurses in the intervention. In one group, the nurses supplemented a team, as an add-on to usual care; in the other group, they worked independently, and were compared directly to a doctor. RESULTS: Nine RCTs were identified and included in this study. All studies were from developed countries, with a medium risk of bias and a moderate heterogeneity between studies. In the five RCTs in which nurse prescribers supplemented a team, there was no significant difference in change of HbA1c compared to usual care (-0.34 percentage points; 95% CI: -0.71, 0.02). In the four RCTs in which nurses replaced doctors, the outcomes of nurse prescribers were comparable to those of doctors. No data on adverse events were available. CONCLUSION: There was no clear evidence of benefit on glycaemic control, when nurses who undertake prescribing work alongside a doctor and other practitioners. However, in those studies in which nurses replaced physicians, the glycaemic control was comparable between nurses and doctors. Therefore, there may be value in providing nurse-led prescribing services where there is limited access to doctor-led services.